TRICARE Covers Banked Donor Milk for Sick Infants
Covered banked donor milk comes from human milk banks accredited by the Human Milk Banking Association of North America (HMBANA). These accredited milk banks are only available in the U.S. and Canada. HMBANA issues safety guidelines on processing human donor milk for member banks. TRICARE won’t pay for milk you get from non-HMBANA accredited banks.
Donor milk may be covered if your baby has one or more of the following serious health conditions:
- Born at a very low birth weight (usually when the baby is very premature)
- A disorder or surgery where the baby’s digestive needs require additional support
- Diagnosed with failure-to-thrive (not appropriately gaining weight or growing)
- Unable to drink formula and the baby’s having difficulty eating or has weight loss
- Low blood sugar
- Heart disease
- An organ transplant
- Other serious health conditions when the use of banked donor milk is medically necessaryClick to closeTo be medically necessary means it is appropriate, reasonable, and adequate for your condition. for the treatment and recovery of the infant
If your baby has any of these conditions and your own milk isn’t available or isn’t good enough in quantity or quality to meet your baby’s needs, then you may be eligible for banked donor milk. TRICARE may also cover banked donor milk in cases where the birth mother is unavailable and the baby has a serious health condition. This could be due to adoption, deployment of the mother, or maternal death.
A TRICARE-authorized provider must prescribe the banked donor milk. A new prescription is required every 30 days, and your baby’s doctor must actively manage your baby’s treatment with banked donor milk. You can only get up to 35 ounces per day, per baby. Coverage may be for up to 12 months of age, as long as it’s medically necessary.
TRICARE has a maximum allowable chargeClick to closeThe maximum amount TRICARE pays for each procedure or service. This is tied by law to Medicare's allowable charges. to cover donor milk screening and processing charges. In some situations, you may be required to pay for the milk upfront and later submit a claim to TRICARE.
Regional contractors are in the process implementing this new benefit and will begin accepting banked donor milk authorizations and claims by the end of May 2019.Learn more about TRICARE coverage for banked donor milk and associated costs.
Last Updated 4/16/2019